(Syn., Perniciosa Typhosa ; Subcontinua Maligna; Subcontinua Typhosa? Acces Pernicieux avec etat Typhoide.)
By typhoid pernicious we understand those cases of malarial infection the general appearance of which recalls typhoid fever. Among the symptoms of typhoid fever it is especially the stupor, the clouding of the sensorium, that is meant, and since the word (Tzucpor, a cloud, exactly expresses this stupor of the intellect, the designation has an etymologic justification. We must confess that by this description no sharp limitation of a definite series of cases is made, and that cases not infrequently occur which would be designated as typhoid by one physician and not by another. Still we may suppose a similar conception in the great majority of cases, for exactly the same differential diagnostic difficulties are present which before Laveran's discovery could be decided only by the autopsy.
It would be a mistake to believe that typhoid pernicious malaria showed always the same picture. Almost exactly the opposite is the case. No other clinical form of malaria shows such a variety of symptoms or would suffer less a schematic representation.
The disease may manifest all its symptoms from the beginning, or be preceded by a few prodromes, or again it may begin as a moderately severe or even mild form of malaria and take on its typhoid character on the third to the fifth day.
The disease may attack those who have never before suffered from malaria , as well as those who have undergone repeated attacks. Yet the latter appear to possess a greater susceptibility, possibly on account of their weakened anemic condition.
The disease frequently begins without a chill, though in other cases this may be present. Moreover, in the course of the disease chills and horripilation may occur.
The principal complaints of the patient are headache, backache, general weakness, restlessness, loss of appetite, thirst, and vomiting. The headache consists sometimes in a tormenting sensation of pressure over the frontal or temporal region; again, of neuralgic pains over different parts of the head. There is more or less stupor, associated sometimes with a tendency to somnolence, again to muttering delirium. The patient sometimes talks in a half loud tone about circumstances connected with his avocation and about things in which he is interested; again he manifests marked excitement in the form of violent delirium, gesticulation, crying, attempts at escape, and more than one of these patients, in an unguarded moment, has thrown himself from the window. The patients often appear as if devoid of intelligence, idiotic, and laugh stupidly. Many cases show an obstinate insomnia, uncontrollable even by large doses of chloral; others again sleep heavily and must be roughly summoned in order to take nourishment, etc.
Secessus involuntarii, on the one hand, retention of urine, on the other, is not rare. A gradual sinking into coma is not uncommon, though this is usually transitory, except where it occurs as an antemortem symptom.
In the general behavior the great restlessness is striking. Patients are continually changing their position in bed, continually abandoning one position for another, without reason. The Romans designated this restlessness " jactationes."
The expression of the face, corresponding to the condition of the sensorium, is variable, though the face always shows characteristic signs of serious disease on account of the anemia and melanemia, to which are often added a slight degree of jaundice and feverish redness. The lips are dry, covered with crusts, and frequently show a slight tremor. The tongue is dry, heavily coated, fissured, swollen, and is protruded tremblingly. If the disease continues some time, especially in the case of a relapse, edema of the feet may occur.
The skin is at different times dry and covered with perspiration; its color is grayish yellow. Herpes, urticaria, and sudamina are frequently seen, and some writers (Negel) claim that they have observed roseola.
The fever may be intermittent or subcontinued (remittent); it may even be quotidian or tertian, though frequently no type can be determined.
In the majority of cases the fever paroxysms are of long duration, extending over thirty six to forty eight hours, and there are physicians who, on this account, describe the fever as continued. Still, from Celsus down the excessive length of the paroxysm in the severe estivo autumnal fevers has been recognized, and the fevers called intermittent; we may, therefore, continue to call them intermittent, even when the fall of temperature occurs only after forty eight hours. These are cases of simple malignant tertian. The symptoms of typhoid pernicious may also be associated with the quotidian type, though we usually have to do in these cases with subintrant fever. This shows a markedly dentate curve with a daily rise and a daily remission.
If the symptoms of the disease are associated with intermittent fever, some of them retrogress with the intermission, to become conspicuous again with the rise in temperature, while others continue throughout the short apyretic interval. The latter is especially true of the stupor, the dry tongue, and the general weakness.
A subcontinued type of fever is more frequent in this condition than an intermittent type, and some writers (for instance, Baccelli) speak, therefore, of a typhoid subcontinued. Since the same symptom complex occurs in both, I prefer to retain the general name, typhoid pernicious, than change it for this narrow one.
At the beginning of the disease intermittent paroxysms may occur for several days, which, by prolongation or doubling, may eventually produce a subcontinued fever. This commencement with intermittent paroxysms possesses some diagnostic value when there is a question of typhoid fever, though this value is limited, since the disease may begin as a subcontinued fever and since there are not rare cases of typhoid fever which begin as intermittents.